Provider Demographics
NPI:1386292217
Name:BENTON, ANDREW MICHAEL (DPT, PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MICHAEL
Last Name:BENTON
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:404-367-2095
Mailing Address - Fax:404-817-0737
Practice Address - Street 1:1000 JOHNSON FERRY RD STE A115
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2110
Practice Address - Country:US
Practice Address - Phone:404-367-2085
Practice Address - Fax:770-579-7060
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist